Emergency Financial Assistance Fund Application
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1
2Emergency Financial Assistance Fund
FOR OFFICE USE ONLY:
Application
APPROVAL CODE:
Date of Request ______________________
Type of Need:
Please check all that apply:
Food (Meals or Groceries)
Crime Scene Clean Up
____BL # ________ OR ____FL # ________
Transportation
Prescriptions (No Schedule II Narcotics)
Glasses
___RA # _________ OR ____Another Pharm.
Dentures
Clothing
Locks
Lodging
Home Repairs
Type of Crime: (i.e. Domestic violence, sexual assault, etc)____________________________________
Date of Crime _______________________County of Crime: ___________________________
Was the crime reported?
Yes
No
Incident Report Available
Yes
No
(If “Yes”, please submit incident report with application; If “No”, give description of crime events – attach
additional paper if necessary)(
Applications received without description or incident report will be denied)
______________________________________________________________
______________________________________________________________
______________________________________________________________
Number of primary and secondary victims that services will assist:
________
Applicant’s Information
Name (First, MI, Last) ___________________________________________________________________
*Social Security #: __________________________*Date of Birth ________________*Age: ___________
(*Full SS# Required for prescription requests ONLY, all other requests, last 4 of SS#; however if the victim doesn’t have a
SS#, leave blank)
Sex:
Male
Female
Race:
Caucasian
African American
Hispanic
Asian
Other
If this victim would like to be added to SCVAN’s Mailing List/Listserv, please include their email address
here:_______________________________________________________________________________________
(OPTIONAL) The following information is needed for grant purposes, please check all that apply to the above listed victim:
Child
Disabled/Handicapped
Native Americans
Elderly
Minority
Annual Household Income:
Under $10,000
Under $20,000
Under $30,000
Number of household members: __________
Victim Service Provider Information
Name __________________________________________ Agency _________________________________
Mailing Address __________________________________________________________________________
Phone ___________________________________ Fax__________________________________________
Email __________________________________________________________________________________
I have received the Emergency Fund Guidelines and Procedures and certify that this application meets the funding criteria and is not
supplanting other resources. I certify that a crime was committed against this applicant (and have provided that information in writing
Signature of Victim Assistance Provider _______________________________________________ Date ________________________
FAX OR EMAIL THIS FORM TO SCVAN FOR APPROVAL – 1.866.473.1272 or
Updated: 10/2015
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Parent category: Business